Performance in community-based management of childhood illnesses and factors associated with its effective implementation in Burkina Faso

doi:10.21203/rs.3.rs-4663096/v1

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Performance in community-based management of childhood illnesses and factors associated with its effective implementation in Burkina Faso

https://doi.org/10.21203/rs.3.rs-4663096/v1

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Background

Burkina Faso gives high priority to improving maternal and child health. Several community interventions have been developed following the adoption of primary health care. Following the adoption of free community care services and the recruitment of community health workers to strengthen community management of childhood illnesses, we conducted a formative performance evaluation and a search for factors associated with its effective application.

Methods

We conducted a descriptive and analytical cross-sectional study using data collected from March 19 to 30, 2023 and January 12 to 30, 2024 in the health districts of Boussé and Boussouma in Burkina Faso through a survey, focus groups and a literature review, then analyzed with SPSS 25 and Nvivo.

Results

Community management of childhood illnesses is implemented in various ways in different health districts. Data from 2017 to 2022 clearly shows that the proportion of malaria cases confirmed with rapid diagnostic tests and treated at community level has evolved globally. On the other hand, management of diarrhea and pneumonia is inadequate. Factors such as the health district of origin, difficulties faced in transporting inputs and the regularity of Community based health workers premium payments determines significantly the availability of curative care in the community.

Conclusions

Despite the measures to provide free care and recruit CBHWs to support the implementation of the Community Integrated Management of Childhood Illness, health facility adherence and a number of other essential factors are hampering the availability of basic care in the desired community. There is an inequity of access to community health care reducing the impact of free health care and the recruitment of community-based health workers on certain populations.

Trial registration

This study used data generated by the system. Surveys and data extraction were carried out after obtaining authorization from the Ministry of Health's Health Research Ethics Committee.

community care

performance

free care

associated factors

community health workers

Burkina Faso

Through its development initiatives, Burkina Faso gives high priority to improving maternal and child health [1,2] with a special focus on primary health care (PHC). Adopted in 1979, PHC was designed to help reduce the burden of morbidity and mortality, while bringing care closer to the community [3]. This concept promotes a strong involvement of populations to promote individual and collective disease prevention actions, but also a stronger involvement of communities in curative care through strategies such as Community Integrated Management of Childhood Illness (iCCM) [4]. To operationalize this curative aspect of the healthcare, Burkina Faso has decided to rely on the setting up of community health agents known as Community based health workers ((CBHWs): "agents de santé à base communautaire" (ASBC)), drawing on previous experience, especially the use of village health agents during the revolution in 1984 [5] and the experience of community health agents in the fight against diseases of special interest such as malaria, HIV/AIDS and tuberculosis [6], and so on. To this end, community health workers were selected in all villages located more than five km from the health center to which they belong, in collaboration with the municipalities, and then trained by the State's technical services; thus harmonizing the profile of the community health worker [7]. The strengthening of community health has been pursued through actions advocated by the national community health strategy, whose 2018 strategy has been completed by an investment file (Ministère de la santé 2019). The extension of free healthcare adopted by the Burkina Faso government in 2016 to community services completed this process of structuring the curative care production chain at community level for children in Burkina Faso (Matt et al. 2020). These practices are of great importance in obtaining the good results described by some previous studies and recommended in particular by the World Health Organization (WHO) [8–10]. The actions of these community agents are complemented by those of community organizations (associations, management committees, etc.), better structured in Burkina Faso and involved in the fight against diseases of interest (Malaria-Tuberculosis-HIV/AIDS) [11].

The implementation of community care has been studied by several authors from different angles. Community-based care and the use of CHWs for this purpose have been implemented in several sub-Saharan African countries. According to some studies, it has improved people's access to care, but has also presented a number of difficulties, particularly in terms of the regular availability of treatment drugs and equipment, capacity-building (supervision and retraining), etc. Their motivation to work was linked to the service they provide to their communities (WHO 2017; Malou Adom et al. 2014; Druetz et al. 2015; Haines et al. 2007; Samuel, Esilaba, et Donde 2020). Successful implementation of community-based strategies should enable populations to access health care closer to home and experience a reduction in morbidity and mortality, as demonstrated by several post-implementation evaluations of iCCM in sub-Saharan Africa [12–14]. It also offered hope of inclusion for hard-to-reach populations, and of improving the country's progress towards universal health coverage [15].

However, the results obtained in this fight against infant and child mortality are still unsatisfactory. According to the 2021 demographic health survey [16], although the mortality rate among children under five has fallen sharply since the 1990s, it is still high, estimated at 48 per 1,000 [17]. In addition, several evaluations conducted prior to the adoption of the major reforms of free health care and the recruitment of CBHWs by the government of Burkina Faso have shown that community care services are insufficiently used by beneficiaries [6,18]. This motivated us to initiate this study to analyse the evolution of iCCM implementation and to investigate the factors associated with its application in two health districts in Burkina Faso.

Type of study

It was a mixed descriptive and analytical cross-sectional study, with data collected in two phases from March 19 to 30, 2023 and from January 12 to 30, 2024.

Concept approach

This study was based on a conceptual model adapted from the health system dynamics framework developed by Olman et al (Fig. 1) [19]. This model enables health system performance to be assessed in terms of effects and impacts resulting from the use of resources and the implementation of activities in a health system. The elements of health system performance described in this framework (in its "OUTCOMES" component) and selected for our study were “access to services, coverage of beneficiaries and quality of care in the context of the aforementioned health districts” which were the focus of a recent study. The indicators used to assess performance trends in the health districts covered by our study were taken from the performance framework of the national community health strategy (2018–2023) [20].

Study framework

The study was carried out in Burkina Faso, a country in West Africa with a pyramid-shaped three-tier healthcare system. The average distance to the nearest health center was 6.1 km [21]. The study was carried out in the health districts of Boussouma and Boussé. Boussé health district (Plateau Central region) covers five (05) municipalities with a population of 199,999 inhabitants and comprises 33 health facilities. Boussouma health district (Center North region) covers three rural municipalities with a population of 239,894, and has 29 health facilities.

Study population

The study covered the population of children under five who had consulted the health facilities of Boussé and Boussouma health districts, household members, CBHWs and health workers in the health facilities of both districts.

Collection tools and techniques

Quantitative data were collected using a survey form administered to households’ members, CBHWs and health center managers, and a grid was used to extract aggregate data from statistical yearbooks (Conseil national de la statistique (cns.bf) [23], which are annual summaries of validated data from the National Health Information System (NHIS), collected from health facilities on a monthly basis. The NHIS is managed by the Department of Sector Statistics of the Ministry of Health, in collaboration with the National Institute of Statistics and Demography [22]. Boussouma health district is a transfer from Kaya health district. It was set up in 2015 and its health information system began full operation in 2016, capitalizing on the performance of Kaya health district. In the qualitative part of our study, focus groups were conducted using a interview grid in villages located more than five kilometers from a health facility.

Variables relating to access, coverage and use of services were assessed.

Sampling

The quantitative component covers all children under five diagnosed with one of the iCCM target diseases in Boussé and Boussouma health scopes, with data aggregated in the statistical yearbooks from 2014 to 2022. The study adopted a variety of multi-stage sampling techniques. Initially, two-stage cluster sampling was used. Given the exhaustive list of villages in the two districts, the villages to be surveyed were drawn at random without replacement. In each sampled village, households were counted and the information entered. Households were drawn at random, the list automatically generated and the heads of household interviewed. All households without children under the age of five were replaced. CBHWs in each sampled village were surveyed. Heads of health facilities located outside the town where the health district headquarters is located were selected on a purposive basis, and interviewed primarily on the basis of the locality security level. Some of these selected villages served as a framework for the focus groups.

Data treatment and analysis

Quantitative data were collected using Excel and analyzed using IBM SPSS 25. Qualitative data were recorded using a Dictaphone, transcribed onto Microsoft word-processing software, and those in national languages were translated into French prior to thematic content analysis.

Ethical considerations

This study was authorized by the Ministry of Health of Burkina Faso and by the National Health Research Ethics Committee of the said Ministry through its deliberation N°2023-03-061. Written consent was requested, with responses recorded on data collection forms, and participation was free and voluntary. The data collected was compiled in an electronic file secured by a code.

During this study, we were able to survey 42 health center managers, including 21 in each district, and 182 CBHWs. The focus groups involved 22 people. Aggregated data from the statistical yearbooks on health center utilization in the two districts, as well as data on the management of malaria, diarrhea and pneumonia, were analyzed. The 2019 data have been corrected with averages, as the data in the directories are adjusted data generated by statistical models to make up for the absence of primary data, which were not transmitted due to a movement by health staff that lasted several months (National Statistics Council (cns.bf).

Change in iCCM coverage from 2017 to 2023

“insert figure 1 here”

An analysis of aggregated data from 2017 to 2022 clearly shows that the proportion of malaria cases confirmed with rapid diagnostic tests and treated at community level has evolved globally following an upward trend since 2018 (figure 1) in Boussouma and Boussé health districts. However, there has been little change in performance in Boussouma health district since 2020.

“insert figure 2 here”

Community-based case management of diarrhea and pneumonia is effective in both health districts (figure 2). It only really began in Boussé health district in 2019 (figures 1 & 2), and is not progressing very well in the management of diarrhea and pneumonia (figure 2).

The survey of health center managers enabled us to assess the level of implementation of this iCCM in 2023. In Boussouma health district, all the health center managers surveyed claimed to provide community management of malaria and diarrhea. However, 14.3% (3/21) did not provide community treatment for pneumonia. In Boussé health district, on the other hand, none of the three iCCM target diseases were fully treated by the health centers surveyed. Our respondents stated that malaria and diarrhea were not being treated in 19% (4/21) cases, and that pneumonia was not being treated in the community in 23.8% (5/21) of cases.

During the focus group discussions, participants confirmed the availability of services and mentioned certain difficulties. Some participants declared the following:

"They visit us to check our children's health during the rainy season. They go round households to distribute medicines to our children. In addition, when we send them a sick child, they do the RDT to see if the child has malaria, and if the test is positive, they give us products to treat the child." Woman_R3_FG18.

"With them, we can get medicines in the village and that saves us going to the health center" Woman_R3_FG5.

"During the rainy season, if a child is sick, we go and see them so that they can perform the screening test to find out what the child is suffering from before going to the health center" Man_R3_FG20.

However, health centers face a problem of drug availability for treatment, as noted by our respondents.

"CBHWs don't have enough medicine to treat children at home. That's why we quickly go to the health center" Man_R2_FG16.

"They often come to see the child and as they don't have any medicine, they send us back to the health center, but if they can treat the illness, if they have the medicine, they give it to us" Woman_R4_FG9.

"In these situations, you have to bypass the CBHWs and go to the health center because they have nothing to treat" Man_R4_FG14.

"Like she said, CBHWs have almost nothing with them therefore we have to go to the health center " Woman_R10_FG19.

Drug shortages are confirmed by health center managers (or representatives). They reported shortages of iCCM drugs in 33.3% (7/21) of Boussé health district and 9.5% (2/21) of Boussouma health district (table 2).

Evolution of health center utilization and performance in malaria treatment.

Evolution of the service usage level by populations from 2014 and 2022.

Analysis of data from statistical yearbooks produced since 2014, shows an almost constant evolution (except in 2017 – 2018), of the number of contacts per inhabitant in Boussouma health district (figure 3) with peaks between 2017 and 2018.

"insert figure 3 here"

This contact per inhabitant has, however, been much improved in Boussouma health district since 2016, and the trend is maintained until 2022 (figure 3).

Trends in annual malaria incidence and case-fatality between 2014 and 2022

The implementation of iCCM should relieve health centers of simple malaria cases and improve the vital prognosis of severe cases.

"insert figure 4 here"

Figure 4 shows upward trends in the annual incidence of malaria since 2016, both in Boussouma and Boussé health districts and in the two health regions (Center North and Plateau Central) to which they belong. After peaking between 2016 and 2018, the annual malaria incidence curve shows little change in Boussé health district and Plateau Central health region, while it is declining in Boussouma health district and Center North health region.

"insert figure 5 here"

Malaria case-fatality has gradually declined in Boussouma health district (figure 5). Overall, it was higher in Boussé district than in Boussouma health district.

Factors associated with the provision of curative care by CBHWs.

In our research for factors influencing the availability of curative care offered by CBHWs through binary logistic regression, we used an "Enter" method to include all explanatory variables in the model, with the existence of curative care in the package they offer as the dependent variable.

All conditions of use were checked beforehand, and the very high probability of X2 (significant p-value at 0.000 (<0.05)) shows that our regression model fits well.

Binary logistic regression enabled us to obtain results indicating that the origin health district, the nature of transport means used to perform services, the difficulties faced in transporting inputs and the regularity of CBHWs' premium payments were the factors that significantly contributed to the prediction of curative care provision by CBHWs at community level (Table 1).

"insert table 1 here"

The sense of coefficients b and Exp(b) indicate that the better the factors of health district of origin, transportation means, means of transporting inputs and regularity of remuneration of CBHWs, the more likely the CBHWs will offer curative care to households.

Though not significant, two elements, namely daily professional activity (p=.076) and the availability of medicines to treat diarrhea (p=.062), attract attention and could be taken into account in the problems to be addressed.

This study noted a variation in the level of iCCM implementation across districts in the assessment of process indicators evolution with data from statistical yearbooks [23] confirmed by the analysis of quantitative data (collected from CBHWs) with logistic regression.

The results of this study show that the use of health facilities improved significantly from the 2016 onwards, and the annual incidence of malaria was greatly influenced by national initiatives (free care at community level and recruitment of CBHWs by the state) which were intended to strengthen the implementation of iCCM. Factors influencing the application of iCCM in the provision of curative care by CBHWs have been identified to guide programmatic managers at the Ministry of Health and Public Hygiene.

Using health services

The results obtained show that health facility utilization improved significantly from 2016 onwards, according to the trend observed in Fig. 4. This corresponds to the development period of one of the flagship health measures in Burkina Faso in recent decades, namely free health care in Burkina Faso adopted by the Government in 2016 [24] for pregnant women, postpartum women and children under five. Our results are in line with those of Matt et al [25] who found that free health care led to increased attendance at health facilities in the early years. In 2018, community services, including curative care offered through iCCM, were subsequently included in the free healthcare basket. In addition to this free care measure, the Government of Burkina Faso recruited, trained and put in place CBHWs in almost all villages. These CBHWs were mandated to conduct awareness-raising activities and curative treatment of uncomplicated cases of the three iCCM target diseases [20]. Changes in attitudes and practices engendered by the implementation of these household awareness-raising activities by CBHWs could be responsible for the improved attendance at health facilities. According to Compaoré et al. [26] these types of communication activities are key in influencing community use of healthcare, and are a key factor in the performance of healthcare workers, as they influence knowledge building, behaviour change and community commitment [27]. The adoption and implementation of public health measures such as free health care and the recruitment of CBHWs by Burkina Faso government have strengthened the framework for the implementation of iCCM in Burkina Faso, a strategy which in itself increases the use of care for childhood illnesses according to Gebremedhin et al. [28].

Coverage trends

According to our results, the implementation of iCCM has improved in recent years, according to the components described in the iCCM guidelines[4]. This improvement is most visible in Boussé health district. These results are undoubtedly the fruit of several years' application of policy orientations linked to primary health care, initiated in the 1980s after the Alma Ata conference [3]. Burkina Faso has successively implemented several community-based interventions, such as the opening of village health posts and the recruitment/utilization of village health agents [5] by the 1983 revolution, "home-based management" (PECADO) of malaria in the 2010s involving community-based distribution of artemisinin-based combination therapies (ACTs) [29] culminating in the service package offered by CBHWs [30].

CBHWs are increasingly applying the guidelines requiring confirmation of uncomplicated malaria cases by rapid diagnostic tests (RDTs) and treatment of uncomplicated malaria cases at community level (Figs. 1 & 2). However, analysis by district shows that implementation in Boussé health district is fairly recent. The difference in the implementation level is supported by the declarations of health center managers or representatives, who stated that, to a significant extent, they did not provide community treatment for malaria, diarrhea and pneumonia in certain health centers in Boussé health district. Similar results were found by Compaoré et al., for whom this diversity of implementation was linked to the different levels of adherence to the strategy by health facility teams [31]. This implementation, which depends on the adherence of health centers, is also in line with the fact that we have identified the district of origin as a factor associated with the existence of curative care in the package offered by CBHWs. This is not favorable to improving access to healthcare for landlocked populations. The consequences are reflected in a higher malaria case-fatality rate in Boussé health district, even though the occurrence of malaria is associated with several factors [32].

In addition, our results show a virtual absence of structured management of diarrhea and pneumonia before 2017, with poor data availability, a shortcoming reported by Quach et al. especially when it comes to disaggregated data [33]. This could reflect the fact that pneumonia treatment was not operationalized despite the strategic orientations. Community-based management of diarrhea and pneumonia was implemented late in the health structures, especially in Boussé health district, starting practically only in 2021. According to health center managers, community-based diarrhea and pneumonia management coverage was insufficient in both districts by 2023. These delays in implementation have had a negative impact on the communities that could have benefited from these services, which, according to Niyibitegeka et al. [34] are highly cost-effective in Burundi for the community management of diarrhea and pneumonia respectively.

The implementation of such care must be properly supervised, as deviations from the guidelines were noted even in health centers by Sanchez et al. [35]. Samuel et al. also demonstrated the need for capacity building in countries where the level of community health workers is unsatisfactory, in order to overcome deficits in services quality [28].

While working on these aspects of iCCM, it is important to ensure that CBHWs, who receive several delegated tasks (immunization, family planning, etc.), are properly supported [7]. In their work, Oliphant et al. noted the risk of a deterioration in services quality due to the overloading of these community players [36].

Analysis of the results shows that annual malaria incidence (Figs. 4 & 5) and malaria case-fatality have evolved at high levels in Boussé health district, in contrast to Boussouma health district. Drawing a parallel with the levels of iCCM implementation, which differed significantly by health district in the logistic regression, we could say that Boussouma health district benefits fully from the improved implementation of iCCM. However, there are problems of equity in the application of these public health initiatives, which are supposed to benefit all populations. Based on the difference in trends in the annual incidence of malaria among children under five benefiting from the free health care measure in the two health districts, we could say that full application of the iCCM has made it possible to contain expenditure on free health care in Boussouma district. Although our data do not allow us to make such a hypothesis for the benefits of effective community management of diarrhea and pneumonia, this cost-benefit ratio for diarrhea and pneumonia has been demonstrated in Burundi [34] and Kenya [37].

In order to strengthen the effects of its flagship measures - free health care and the use of community players - Burkina Faso's Ministry of Health will need to make additional efforts to ensure effective scaling-up in order to resolve these problems of equity of access, for which iCCM is very well suited, according to Oresanya et al., who worked on community interventions to improve coverage of hard-to-reach populations in Nigeria [38]. Projects to strengthen community health will have to address the problems of drug availability reported by health center managers, which, although not significantly associated with the existence of curative care in the package offered by CBHWs, is at an important level of significance (Table 1). These problems of input availability for the implementation of iCCM have been reported by [6,31,39] in the context of Burkina Faso, but also in other contexts such as Ethiopia [40]. Effective availability of healthcare products will be a key factor in retaining people's loyalty to the healthcare system, and solving this problem will also involve strengthening governance, in line with the findings of Allen et al., who identified national leadership, data production and sharing, and reducing dependence on external funding [41] as the main challenges to overcome.

This study enabled us to detect an inequity in the application of policies designed to reduce the burden of malaria, diarrhea and pneumonia. Boussouma health district, which had a better application of iCCM to combat the three diseases, recorded lower levels of annual malaria incidence and lethality, with a probably reduced financial burden on the funds dedicated to free health care in Burkina Faso. The Government of Burkina Faso should strengthen the monitoring of the strategy implementation and act on the associated factors identified by this study to ensure greater equity in the provision of curative care in the community. There is a need for an economic evaluation to measure the comparative advantages of the full application of iCCM in a context of free health care, as applied by Burkina Faso, in terms of efficiency.

This study, using data generated by the system, enabled us to detect inequity in the application of policies designed to reduce the burden of malaria, diarrhea and pneumonia. The Boussouma health district, which had a better application of iCCM to combat the three diseases, recorded lower levels of annual malaria incidence and lethality. Stakeholder buy-in is also an important factor in achieving better results, because despite the measures taken to facilitate the application of iCCM, we note that some health centers are not actually applying iCCM, even in 2023. this is likely to impose a financial burden on the Burkina Faso government in implementing its policy of free healthcare, and increase household healthcare expenditure. In view of the results achieved in the fight against these child-killing diseases, the Burkinabe government should ensure that the implementation of the strategy is monitored and controlled more closely, and increase funding for iCCM drugs, with a sound strategy for purchasing the results from health centers. Better structuring of this intervention according to the distances covered by the CBHWs, with substantial investment in the means of implementation to increase efficiency and improve impact. An economic evaluation is needed to measure the comparative advantages of the full application of iCCM in a context of free health care as applied by Burkina Faso in terms of efficiency.

ACT

Artemisinin-based combination therapies

AIDS

Immunodeficiency syndrome

CBHWs

Community based health workers

CNRST

National Center for Scientific and Technological Research

DRSHP

Regional Health and Public Hygiene Director

ED-2S

Health Sciences School

HIV

Virus de l'immunodéficience humaine

Focus group

iCCM

Community Integrated Management of Childhood Illness

IRSS

Institute for Research in Health Sciences

ISSDH

Institute of Sport Science and Human Development

ISSP

Higher Institute of Population Sciences

MINEFID

Ministry of Economy, Finance and Development

PECADO

Home-based management

PHC

Primary health care

RDT

Rapid diagnostic tests

SPSS

Statistical Package for the Social Sciences

UFR/SDS

Health training and research unit/ Health Sciences

WHO

World Health Organization

Ethics approval and consent to participate

This study was authorized by the Ministry of Health of Burkina Faso and by the National Health Research Ethics Committee of the said Ministry through its deliberation N°2023-03-061

Consent for publication

Not applicable

Availability of data and materials

Data and materials supporting the results of this study are available on request from the corresponding author Ouedraogo Hamed Sidwaya

Competing interests

The authors declare that they have no financial or personal relationships that may have influenced them in the writing of this article.

Funding

The authors received no financial support for the research, writing and/or publication of this article.

Authors' contributions

Hamed Sidwaya Ouedraogo: Conception or design of work, Collection of data, Analysis and interpretation of data, Drafting of article, Critical revision of article, Final approval of version to be submitted

Ahmed Kabore: Conception or design of the work, Drafting of the article, Critical revision of the article, Final approval of the version to be submitted

Badra Ali Traore: Conception or design of the work, data collection, critical revision of the article, final approval of the version to be submitted

Moumai Mano: Analysis and interpretation of data, Drafting of the article, Critical revision of the article, Final approval of the version to be submitted

Sohinte Some: Analysis and interpretation of data, drafting of the article, critical revision of the article and final approval of the version to be submitted.

Boezemwende Ouoba/Kabore: Analysis and interpretation of data, Drafting of article, Critical revision of article, Final approval of submitted version

Massoudou Harouna Maiga: Conception or design of work, Collection of data, Analysis and interpretation of data, Critical revision of article, Final approval of version to be submitted

Abdramane Soura: Conception or design of work, Analysis and interpretation of data, Drafting of article, Critical revision of article, Final approval of submitted version

Maxime Koine Drabo: Conception or design of work, Analysis and interpretation of data, Drafting of article, Critical revision of article, Final approval of submitted version

Acknowledgements:

We would like to thank the DRSHP teams in the Center Nord and Plateau Central regions and the community stakeholders who helped us conduct this study.

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Table1: Factors associated with the existence of curative care in the care package of CBHWs

		B	Wald	ddl	Sig.	Exp(B)	Confidence interval 95% for EXP(B)
		B	Wald	ddl	Sig.	Exp(B)	Lower	Higher
Pas 1^a	Sex (1)	,059	,010	1	,921	1,061	,329	3,419
	CBHW status		1,292	2	,524
	CBHW status (1)	-1,985	,925	1	,336	,137	,002	7,848
	CBHW status (2)	-1,216	1,041	1	,308	,297	,029	3,063
	Distance from living village to HF	,109	1,264	1	,261	1,115	,922	1,348
	District (1)	-2,498	16,400	1	,000	,082	,025	,276
	Age (in years)	,005	,019	1	,889	1,005	,941	1,073
	Education level		2,651	4	,618
	Education level (1)	-4,141	,000	1	1,000	,016	,000	.
	Education level (2)	-19,999	,000	1	1,000	,000	,000	.
	Education level (3)	-22,235	,000	1	1,000	,000	,000	.
	Education level (4)	-21,715	,000	1	1,000	,000	,000	.
	Marital status		,234	3	,972
	Marital status (1)	-20,166	,000	1	1,000	,000	,000	.
	Marital status (2)	2,817	,000	1	1,000	16,721	,000	.
	Marital status (3)	-19,411	,000	1	1,000	,000	,000	.
	Daily professional activity		3,372	5	,643
	Daily professional activity (1)	,479	,215	1	,643	1,614	,214	12,206
	Daily professional activity (2)	1,546	3,145	1	,076	4,692	,850	25,902
	Daily professional activity (3)	,534	,587	1	,444	1,706	,435	6,694
	Daily professional activity (4)	19,505	,000	1	1,000	295611363,344	,000	.
	Daily professional activity (5)	,226	,032	1	,858	1,254	,106	14,829
	Seniority of community activities (in years)	-,058	,551	1	,458	,944	,810	1,099
	Do you have RDTs for malaria screening? (1)	-,031	,001	1	,977	,969	,112	8,401
	Have you experienced a shortage of medicines for IMCI (malaria, diarrhea, pneumonia)? (1)	,382	,388	1	,534	1,466	,440	4,883
	28. Do you have medicines to treat malaria? (1)	-,035	,001	1	,973	,965	,123	7,547
	28. Do you have medicines to treat diarrhea? (1)	-2,185	3,496	1	,062	,113	,011	1,111
	28. Do you have medicines to treat pneumonia? (1)	2,284	2,479	1	,115	9,811	,572	168,388
	What means of transport do you use to provide community services (care and outreach activities) for children?		6,865	2	,032
	What means of transport do you use to provide community services (care and outreach activities) for children? (1)	-,713	,731	1	,393	,490	,096	2,513
	What means of transport do you use to provide community services (care and outreach activities) for children? (2)	-1,612	6,839	1	,009	,200	,060	,668
	Are you facing difficulties in transporting inputs? (1)	-1,074	4,139	1	,042	,342	,121	,961
	Do you have a diarrhea management kit? (1)	-1,613	,868	1	,352	,199	,007	5,931
	Do you have a pneumonia management kit? (1)	-1,760	2,225	1	,136	,172	,017	1,738
	Have you had a shortage of RDTs over the past 3 months? (1)	-,365	,200	1	,654	,694	,141	3,428
	Do you regularly receive government bonuses? (1)	-1,728	8,055	1	,005	,178	,054	,586
	Constant	46,887	,000	1	,999	230589840930864820000,000

Table 2: Level of breakdown in health facilities by district (n=42).

		Proportion of respondents per health district
		Boussé (%) (n=21)	Boussouma (%) (n=21)
Shortage of medicines for iCCM (malaria, diarrhoea, pneumonia) registered	No	66,7	90,5
	Yes Total	33,3 100,0%	9,5 100,0%

No competing interests reported.

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Performance in community-based management of childhood illnesses and factors associated with its effective implementation in Burkina Faso

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